COVID-19 Vaccine Hesitancy in Trinidad and Tobago: A Qualitative Study

Background After three years of COVID-19, the WHO declared that the pandemic was no longer a global health emergency. Vaccination remains part of the management strategy, given the current phase of the pandemic. This study explored the reasons for COVID-19 vaccine hesitancy in Trinidad and Tobago (TT). Methodology A qualitative study of persons 18 years and over from the eastern, northwest, northcentral, and southwestern geographical areas of TT, who are unvaccinated and hesitant, was done by convenience sampling. Formal in-depth virtual interviews were done on a one-to-one basis using a semi-structured questionnaire. The interviews were recorded and transcribed using the principles of reflexive thematic analysis of participants' responses. Results From 25 participants' responses, the main themes for being vaccine-hesitant were fear, inefficacy, information inadequacy, perceived susceptibility, mistrust, herbal alternatives, and religious hesitations. Additionally, their motivations for receiving the vaccine in the future were surrounded by themes of necessity, perceived susceptibility, health benchmark, and assurance. Conclusion and recommendations This qualitative investigation identified traditional factors contributing to COVID-19 vaccine hesitancy and unique determinants such as herbal use and religious beliefs within the TT context. These insights could inform future research and facilitate the development of tailored strategies to address persistent vaccine hesitancy for COVID-19.


Introduction
As of July 2023, there have been over 700 million confirmed cases of COVID-19 globally, with almost 7 million deaths [1]. Trinidad and Tobago (TT) has not been spared, with over 191,000 confirmed cases and more than 4,300 deaths in July 2023 [2]. Geographically, TT is in the southern Caribbean and is a twin island state with a population of approximately 1.5 million [3]. Despite the availability of COVID-19 vaccines in TT since April 2021, the percentage of persons in May 2023 who completed a vaccination regimen stood at approximately 50% [4,5]. This was below the anticipated 63% of those who expressed willingness to take the shot before COVID-19 vaccines became available in TT [6]. Two studies have been done for healthcare professionals in TT documenting good COVID-19 knowledge, positive attitudes, and perceptions [7,8]. Reasons for vaccine hesitancy among TT primary care workers were fear of adverse effects, lack of information, and inadequate duration of trials [7]. In the study of TT dentists, about one-tenth of respondents expressed safety concern, and two-fifths were worried about side effects. A TT study in pregnant women revealed a COVID-19 vaccine uptake of 24%, with most women expressing fear that the vaccine would harm their babies or that insufficient data was available [9].
In May 2023, the WHO determined that COVID-19 was no longer a public health emergency of international concern, and the integration of COVID-19 vaccines as part of life course programs was amongst its recommendations [10]. This underscores the importance of COVID-19 vaccination even in the devolving stage of the pandemic, particularly for high-risk groups. The low COVID-19 vaccination coverage rates seen in TT can be due to various factors unique to this setting contributing to vaccine hesitancy. The local studies highlighted above were cross-sectional by design. This research aimed to explore the reasons for vaccine hesitancy in the TT population.

Study design, setting, and sampling
This qualitative study was conducted in TT from March to May 2022, a transition time when governmental restrictions on social gatherings, mask-wearing, and travel requirements were relaxed [11]. With fewer than 50% of the population vaccinated during this time, the unvaccinated population served as the main group from which participants were drawn. Contacts of the authors, residing in the four main regions of TT, were recruited through convenience sampling using personal correspondences and social media. Included in the study were adults who had not received the COVID-19 vaccine and were hesitant to do so, along with their informants. Fully vaccinated individuals, those willing to obtain the vaccine soon, and vulnerable populations, including children, prisoners, and mentally disabled persons, were excluded from participation.

Data collection, analysis, and validation
Given the restrictions present at the time and the hesitancy of respondents to meet face-to-face, individual virtual interviews were conducted to explore vaccine hesitancy in T&T. The semi-structured questions asked were: 1) 'Tell me about your reasons for being unwilling to receive the COVID-19 vaccine.' 2) 'Would you ever consider becoming vaccinated in the future? (If yes) What would make you more open to receiving the COVID-19 vaccine in the future?' These questions were developed by the researchers after reaching a consensus based on their informal discussions with personal vaccine-hesitant contacts. Audio recordings of the interview sessions were made by each interviewer using the Blackboard Collaborate Ultra web conferencing system, available to the researchers through their institution. The interview was recorded automatically online from the start to the end of the conferencing call for the duration of the interview. All audio recordings were later transcribed verbatim using Otter.ai software [12].
The analysis of data was done using the principles of reflexive thematic analysis using an inductive approach. For initially apparent omissions or errors, transcripts were reviewed together with the matching audio recording. The data was anonymized and recorded using participant numbers in Word (MS Office). The research team collectively read the transcripts to gain familiarity with the data and a broad understanding of the content. Independent researchers organized each transcript into codes in Excel (MS Office), with the senior researcher reviewing them. Preliminary themes were derived by individual researchers, and consensus meetings were held to review and refine the themes. Participant validation was used, wherein respondents were asked to review the transcripts and themes for agreement and refinement. Recruitment was halted when saturation occurred from the ongoing analysis of the data. Themes were tabulated with supporting quotations.

Ethical considerations
Participant consent was obtained prior to the interviews via an online form that guaranteed the collection and storage of anonymized data. Ethics approval was obtained from The University of the West Indies Ethics Committee (Ref: CREC-SA.1389/02/2022).

Results
The characteristics of the participants are shown in Table 1. There were 13 females and 12 males, ages 20-83, from both rural and urban regions on both islands.

Reasons for not getting COVID-19 vaccine
In this study, several themes emerged as to why participants were hesitant to be vaccinated against COVID-19. These themes were: fear, inefficacy, information inadequacy, perceived susceptibility, mistrust, better alternatives, and religious hesitations ( Table 2).

Sub-theme Supporting quotation
Fear Safety in Pregnancy "And next thing that is a next concern is pregnant women taking COVID-19 vaccines because to me like when you're pregnant, you hardly can take anything, can't take a tablet, you can't take certain things.

Motivations for receiving COVID-19 vaccine in the future
Based on the plethora of information received from participants, there were many reasons why they would be motivated to take the COVID-19 vaccine in the future. The main themes arising from these motivations were: necessity, perceived susceptibility, health benchmark, and assurance.

Discussion
In this TT study, participants expressed various reasons for being hesitant about the COVID-19 vaccine.
Most of the themes identified in this study were also identified in the systematically reviewed literature [13]. A thematic synthesis on qualitative research surrounding COVID-19 vaccine hesitancy described themes of "institutional mistrust," "lack of confidence in vaccine and vaccine development process," "lack of reliable information or messengers," "complacency/perceived lack of need," and "structural barriers to vaccine access" [14]. These overlap with the themes of inefficacy, information inadequacy, perceived susceptibility, and mistrust, as seen in this study. This study generated sub-themes of concerns surrounding death and adverse effects from the vaccine, safety in pregnancy, and effects on pre-existing medical illnesses. This overarching theme of fear was highlighted in a study that examined the fearful impact of the arrival of the COVID-19 vaccine on a global scale [15]. Vaccine novelty, misinformation, and uncertainty are possible explanations for this effect that were also described in this study.
Several interventions have been explored for reducing COVID-19 vaccine hesitancy. Most observational studies have described the benefits of appointment reminders, opt-out scheduling systems, multi-modal interventions, and infographics [16]. The themes identified in this study are amenable to such tactics. While the vaccine hesitancy themes identified are not unique to our setting, interventions for these factors can be contextualized to the local setting. TT is a very multicultural society, with several religions being subscribed to [17]. Religiosity and its positive correlation with life satisfaction have been demonstrated in the Trinidadian context [18]. However, when it comes to COVID-19 vaccination, spirituality has been negatively correlated in various settings globally [19]. A regional Jamaican study, however, found that support from religious leaders reduced COVID-19 vaccine hesitancy [20]. This speaks to the potential influence that spiritual factors can have in promoting or discouraging behavior. Involving TT's multiple religious bodies in future vaccine uptake efforts will be key to reducing vaccine hesitancy.
Another theme that arose in this study was that of herbal use. The perception that complementary medicines can be protective against COVID-19 was depicted in this study. While the data on herbal options to prevent COVID-19 infection appear mostly theoretical, others have called for research into locally available natural compounds [21,22]. TT has a history of many well-documented naturally occurring remedies, some of which are more popularly used than others [23,24]. Anticipatory guidance, given our familiarity with the natural remedies being used in TT, may help reduce misinformation where mindsets exist about herbs as an alternative to vaccine-induced immunity [25].
Though participants of this study were vaccine-hesitant, they were not opposed to the idea of getting vaccinated in the future. Motivating factors were necessity, perceived susceptibility, need for assurance, and health benchmark. The notion of having to attain ideal health before receiving the COVID-19 vaccine was seen in our study. Fear of receiving the vaccine due to ill health was also voiced. It was interesting that the susceptible persons felt medical illness disqualified them from vaccination when, in fact, they are the highrisk group who may stand to benefit the most. Dissonance-based interventions have been suggested by some as a means to counteract such misperceptions [26]. Vaccine education that is personalized to the local context, based on qualitative work, does have a role in producing tailored interventions [27].
A strength of this work was the diverse demographics of the participants spanning a wide age group and diverse geographic locations. Member checking also added to the credibility of the findings. This study uncovered nuanced findings surrounding local herbal and religiosity factors as they relate to COVID-19 vaccine hesitancy.
There are some limitations to this work. Focus group interviews were initially intended for gathering data in this qualitative study. However, during the recruitment process, we found that several participants expressed discomfort in sharing their views in the presence of others, even if their identities were kept anonymous. As a result, it was necessary to adjust our approach and utilize online one-to-one interviews. This approach still allowed us to explore the complex perceptions, attitudes, and beliefs surrounding the topic. While we also conducted online interviews, face-to-face interaction might have enhanced communication and the quality of information shared; however, this was not possible given the state of restrictions at the time of the study. Lastly, it is possible that individuals or groups with unique vaccine-hesitant factors remain unexplored by this study. We did not use stratified sampling, which could have captured a greater diversity of subgroups for exploration, such as pregnant women and health care providers.

Conclusions
This qualitative study delved into the reason for COVID-19 vaccine hesitancy. While it reaffirmed common global factors like concerns about vaccine safety and mistrust in healthcare institutions, it also unveiled unique elements contributing to vaccine hesitancy in TT. Using herbal remedies and strong religious beliefs emerged as factors with local underpinnings. The herbal culture and faith-based attitudes present unique challenges to vaccine uptake within this context.
These findings not only contribute to a more profound understanding of vaccine hesitancy but also pave the way for further research. By recognizing these factors, tailored vaccine uptake campaigns can be developed, catering to the specific needs and beliefs of the TT population. As the world continues to grapple with COVID-19, alongside other infectious diseases, understanding and addressing the roots of vaccine hesitancy, remain crucial.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. The Ethics Committee of Paraclinical Sciences, The University of the West Indies at St. Augustine issued approval CREC-SA.1389/02/2022. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any